Change Project 911: Help! My Project Is Dragging on Too Long

Mat Roosa, LCSW-R
NIATx Coach

The Problem 
Change projects are not meant to be open-ended. They’re meant to move quickly and efficiently to extract the maximum benefits. Dave Gustafson, who developed the NIATx model, recommends limiting change projects to no more than a few weeks. Some change projects can be completed successfully in as little as a day. If you find your team in the middle of a never-ending project, try to diagnose the root cause that’s derailing the project.

Any one of these underlying problems could make a change project drag on:

1. Vague aim statement. A change project without a specific, time-limited goal can drag on indefinitely.
The Fix:  Watch your “altitude.”

Some aim statements aim too high (“Improve service quality”) and do not provide any focus for the team. These vague aims are like asking where to find a product in a big-box hardware store and being told, “Yeah, we have that! It’s in the store somewhere.” That’s not enough detail to move you in the right direction.

Other aim statements may aim too low: “Improve the friendliness of the first statements delivered to customers on their first visit.” These types of aim statements are too specific to create much energy or have much impact. Sometimes these low altitude aims end up looking more like a specific strategy. Start with a more straightforward “mid-altitude” aim to ensure clarity for your team. For example: “Improve the first session experience for clients to increase the session 2 show rate by 30%.”

Ask the following key question to identify low-hanging fruit:

What can we do right now that we all agree would result in an improvement?


1. Fix simple technology glitches that reduce access. Any easy fix? Update a long or obsolete voicemail menu.

2. Create a welcoming environment. A fresh coat of paint on the walls and a new lamp are inexpensive improvements that can go a long way in enhancing the customer experience.

3. Engagement scripts. Follow the lead of many customer service efforts in retail environments: train staff to use key language and phrases to connect with clients and increase continuation in care.

• Use a simple aim statement recipe:  "Increase A from B to C by Date D." Almost any change project aim can be plugged into this formula to add clarity.

• Limit the project length!  It’s easy to forget that we call it Rapid-Cycle Change for a reason. Establishing a shorter time frame will push the team to choose projects that can have a measurable impact in the shorter term. “Sometime early next year” does not count as a completion date. Deadlines can help create a sense of urgency that can motivate the team to keep things moving. The “T” in SMART goals stands for “time-bound” as the project's time frame is critical to a precise aim.

• Pick a measure that the team can monitor easily and frequently. Imagine that you are driving down a twisty country road in the dark. Now imagine that your headlights only shine once every 10 seconds for a single second. How long would it take you to complete your journey? Teams find themselves in a similar dilemma when measuring elements with low frequency or elements for which data is not frequently available. The team is then stuck moving very slowly toward its goal, with limited capacity to gauge success.

2. Lack of regular change team meetings. Projects can flounder if change teams don’t meet regularly to monitor PDSA cycles, analyze data, and brainstorm.


• Use existing meetings Sometimes a change team meeting can be tacked on to the front or the back of a standing staff meeting to ensure attendance and efficient use of time.

• Keep change team meetings short A brief and frequent approach to meetings can foster attendance, as members feel a stronger return on their time investment.

• Executive sponsorship Leaders can be critical in setting expectations for the change team related to regular meetings and project status updates.

About Change Project SOS

Change Project SOS is a monthly blog post series covering common change project barriers and how to address them. Has your change project hit a wall that you're not sure how to tackle? Share your story in the comments section below, or email Change Project SOS at We’ll offer solutions from our team of change project experts!

About our Guest Blogger

Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in quality improvement, organizational development and planning, and implementing evidence-based practices. Mat also serves as a local government planner in behavioral health in New York State. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat (Change Project SOS) at

Thriving in Survival: Holidays 2020

Jesse Heffernan
CCAR Core Trainer and Recovery Coach Professional

As we start to prepare, or continue, to celebrate the 2020 holiday season, it goes without saying that this will be perhaps one of the most stressful and difficult ones in recent times. The pressure and influence of the COVID-19 pandemic has caused many folx in recovery and supporting fields to assess this year differently. For many in or seeking recovery, the holidays may already activate any number of traumas or personal “stuff” causing some to be more susceptible to symptoms of recurrence or heavier use. We may also experience the effectiveness of our self-care strategies lessening through this time, which does not mean we are failing, it instead indicates we are experiencing something new or extra challenging. We need to remember there are ways to successfully navigate the holidays — and we can ask family, friends and colleagues to help.

One of the ways we can mitigate the stress of the season is planning and boosting our self-care before the holidays kick in. We can do this by focusing not just on engagement in recovery supports, but also on staying on track with a holistic approach to support our physical, emotional, mental, and spiritual well-being. Every individual's recovery looks different and with the help a counselor, mentor, recovery coach, or sponsor we can have a plan ready. (We also want to consider other factors, like equitable access to services and promoting multiple pathways of recovery, which includes medications and moderation.)

 Here are some suggestions that may help you out:

1.      Check in with yourself first. A great tool to use is the P.I.E.S. list. It stands for Physical, Intellectual/Mental, Emotional, and Spiritual or Social. Looking at where we are at in these areas before we make connect digitally or in-person is a good way to give ourselves the time and space to reflect.

2.      Take some digital breaks. With so much of our time and energy taking in place in front of screens, planning some time off from them can help you reset and take some time to breathe. Gratefully, there are apps that can help us keep track of our screen time and set reminders.

3.      Check in on someone else or volunteer. Checking in on friends, family or co-workers is a great way to get outside of ourselves in a healthy way. Service and connection can help us gain perspective and support others.

4.      Building your network, part 1. Attending more recovery support meetings so you are walking into holiday get-togethers with a good foundation and connection to your recovery. There are several platforms that offer free digital support meetings such as In the Rooms. Some in-person meetings have started back up; be sure to make sure they are following all COVID-19 precautions.

5.      Build your network, part 2. Get numbers and social media usernames of other people in recovery and keeping them available just in case you need some extra support. Also consider helping others by committing to calling three or four people who might be struggling (see number 3). 

6.      It's OK to say no and it’s ok to leave. We may at some point felt we had to attend gatherings or events out of a sense of amends or obligation. If you are compromising your own recovery or integrity to be around people who are excessively using or making you uncomfortable, you have the right to decline or leave. Having an exit plan for gatherings or events and a way to get home that is not dependent on others. 

7.      Create your own traditions and meaning. If the stories and memories of the holidays are not happy or align with you, this is the chance to make up new ones. There are several alternative practices and ideas out there that might fit for you. You may also re-examine your current traditions and find deeper meaning in them. This is a time to give yourself room to create or commit to something meaningful for you.

8.      Brave conversations instead of confrontations. The holidays can be a time to try new tools of boundaries and practicing emotional intelligence. Even if we are triggered by a family member or lured into a loaded conversation regarding politics or beliefs, we can simply say this may not be the best time. You can also do some practicing beforehand with someone you trust to make sure you are anchored in your responses and personal values.

9.      It’s about wellness, not perfection. We can often be hardest on ourselves more than anyone else. Work on showing yourself the same, or more, levels of compassion you might have for someone else. Put your wellness and recovery first. In the book The Four Agreements, it’s called Always Doing Your Best. Our best changes from moment to moment and cannot be compared to anyone else’s.

Again, these are just some suggestions, and you may have some great ideas to add. The more we do to meet people where they are at on the journey, the more opportunity we have to thrive in the survival of 2020. Have safe and happy holidays!



NEW WEEKLY MEETING: The Recovery Coach Connection  

This will be a weekly meeting for Coaches and Peers to learn from others in the field, explore the art and role, and receive support. In each meeting, we will focus on a topic or bring in a different guest to share their experience on topics relevant to the recovery coaching field and movement and answer your questions. Meetings will take place on the second Monday of every month at 8 p.m. CST / 9 p.m. EST.

Join here:


Jesse Heffernan is a person in long-term substance use and mental health recovery. He is a CCAR Core Trainer and Recovery Coach Professional. Throughout his professional career, he has worked as the Program Director for one of Wisconsin’s three mental health peer-run mental health respite facilities, the Outreach and Empowerment Coordinator for Faces & Voices of Recovery and currently is the Co-Owner of Helios Recovery services. He lives in WI with his partner and 4 children, enjoying all things in geek culture, basketball, and coffee. It is his belief that Recovery is the process of returning to inherent worth and dignity.

About Helios Recovery:
Helios Recovery Services inspires and ignites leaders through training, consulting, and advocacy that focuses on core elements that help create healthy, responsible, and thriving individuals and communities.

Learn more at and see more recovery related blogs by Jesse Heffernan here.

Peer-Based Training Brings Collaboration to those who Serve Pregnant and Parenting Women

Erika Holliday, MPH
Mid-America Addiction Technology Transfer Center

Inspiration can often come from collaboration and growth amongst like-minded individuals. Finding a community that shares critical life experiences can transform into impactful change at the organizational and community level. Creating such community was an unforeseen joy that sprouted from one of the Mid-America ATTC’s latest programs, “Providing Peer Based Recovery Support Services for Pregnant and Parenting Families,” a two part training and 6-week learning collaborative for peer specialists/recovery coaches and supervisors of peer specialists who want to develop expertise in serving pregnant and parenting families impacted by substance use and/or opioid dependence. The National Opioid Response Network developed the training curriculum and Mid-America ATTC requested permission to pilot the curriculum. In collaboration with the regional ORN TAP J 15.

The training was created by Sharon Hesseltine, the President and CEO of New Beginnings Consulting and Training, and Lonnetta Albright, President and Owner of Moving Forward Inc. The training focused on being recovery-oriented, and person-centered, and looked at key functions such as recovery planning. Challenges from working in diverse settings such as health care or child welfare were explored as well as aspects of the work that is unique to Peers who support pregnant and parenting families. The training also looked at the relationship around the process of becoming a family through pregnancy, delivery and parenting babies who have experienced Neonatal Abstinence Syndrome and/or Neonatal Opioid Withdrawal Syndrome (NAS/NOWS.)

The Peers training was a great success. The training evaluation indicated that 100% of participants deemed it to be useful, would recommend it to others, and were confident they could apply what they learned to their work as Peer Recovery Support Specialists, or a supervisor of Peer Specialists. More than learning new, important skills, participants indicated they found a new sense of community. One of the participants shared these thoughts with the Mid-America ATTC about the training:

“I have not had training in this area so it was very helpful and reminded me that the effects of mood-altering substances start at conception for our little ones. I really enjoyed getting to collaborate with other professionals in different states on how they run their organizations. I will definitely be focusing on building on strengths with our ladies and pointing out the strengths that our children have and how that plays a role in our daily lives as parents. Thank you so much for the opportunity to get to learn more and make new friends.”

Another participant shared:

“As a recovery coach I have the experience of my own recovery as a tool that can be used to help those new to recovery. With this training I was able to fill my tool bag. So much I learned! Thank you for sharing the wisdom that was given. I can only hope that I will be able to make an impact on the lives of others I get to help.”

The Mid-America ATTC is so pleased to assist in providing impactful knowledge and relationships with those on the ground who are making an effective difference in the field of substance use recovery. With the overwhelming success of this training, we plan to offer it again in 2021, and potentially more often as the work continues.


Finding New Ways to Connect During Isolation

Jeff Ledolter
National American Indian & Alaska Native Addiction Technology Transfer Center

When COVID-19 was declared a pandemic in March 2020 and services began shutting down, many clinics were at a loss for what to do. Facing an unprecedented challenge, health providers had to make tough decisions with incomplete information on how they could best help their patients. They had to weigh the possible effects of exposing their patients to an unknown infectious disease against the behavioral health problems that they knew could cost their patients their lives. It’s been commonly said that addiction is the opposite of connection. How could a counselor advocate for their patients to socially distance when they knew it would put patients at greater risk of relapse and overdose?

Health providers were not alone in facing this decision. Almost every organization, including our three American Indian and Alaska Native technology transfer centers, was forced to adapt to the new normal of isolation and severing of connections. We’ve long been an advocate of hosting in-person training sessions and events. The relationships and trust that we have with our network of providers are based on face-to-face interactions. It not only embodies the harm reduction approach of meeting people where they are but acknowledges their tribal connections with their lands and shows that we are committed to helping improve their communities.

After some consideration, each of our centers began a series of listening sessions. Every week, we would invite providers to our Prevention, Mental Health, and Addiction TTC listening sessions to hear what was happening in their communities and allow them to connect to a world they were no longer permitted to attend. Originally, these sessions were an opportunity for grantees to vent their frustration and compare their situations with others. Over time, as people got used to the new format and began seeing familiar faces on these calls, they began opening up and sharing more about their individual and community challenges. They began comparing strategies that they’d found useful when faced with an unprecedented challenge and began accepting help from each other. Connecting these virtual neighbors allowed them to improve their practices by comparing the relative effectiveness of different treatment and prevention approaches in native communities.

Telecommunication events are still imperfect and may never match up to the connection found in face-to-face interactions. I’m sure that most professionals are too familiar with the audio/video problems and awkward delay problems that come with teleconferencing. Still, keeping that connection alive during these stressful times is more important than ever.

Unfortunately, 8 months since it was declared, the pandemic is still not over. Even worse, providers are already beginning to see the wave of mental health and substance use disorders that follow a period of stress, uncertainty, and isolation. To date, our centers have hosted over 100 of these listening sessions and we plan to continue them for as long as they are useful, perhaps even once we’re able to meet face-to-face again. Even through this virtual meeting space, we’ve seen once again the kind of resilience that Native communities display when relying on cooperation, empathy, and trust.

For an overview our listening sessions, please visit our webpage here:

Strategies for Addressing Stimulant Use Among Women: An ATTC Collaborative Project ECHO Series

Maureen Nichols
Director, South Southwest Addiction Technology Transfer Center
HHS Region 6


Pat Stilen
Director Mid-America Addiction Technology Transfer Center
HHS Region 7

Thomasine Heitkamp
PI and Co-Director
Mountain Plains Mental Health Technology Transfer Center Mountain Plains Addiction Technology Transfer Center
HHS Region 8

An overriding concern in the behavioral health field in HHS Region 6 in the past several years is the continued impact of stimulant use on individuals in our states and tribal communities, and the need to promote effective, evidence-based and holistic strategies for recovery and wellness for this population. Taking a focused approach on the specific needs of women who use stimulants, three regional ATTCs brought together their collective expertise to develop a Project ECHO series that the utilized case-based learning model to build community capacity to address this growing epidemic: Mid-America ATTC, a leader in evidence-based treatment for pregnant and post-partum women, Mountain Plains ATTC, with expertise in serving rural populations, and the South Southwest ATTC with experience in implementation of substance use peer recovery services. Each Project ECHO session included a didactic presentation followed by one or two de-identified case presentations related to stimulant use among women. All the case scenarios (required in an ECHO Model) had a stated goal of reunification of children with mothers who were struggling with a stimulant use disorder. This underscored for the cross-regional ATTC team the needs to work “hand in glove” with professionals with expertise in child welfare practice and encouraging cross-disciplinary efforts. The case reviews also underscored the limitation of resources to support mothers, especially in rural communities.

Results of this collaborative project advanced behavioral health service improvement in several ways:

Advancement of participant knowledge, skills and resources: The presentation of evidence-based approaches targeted to the specific target population of women who use stimulants and the productive discussion of specific, complex and challenging case presentations provided participants from across the primary and behavioral health care systems effective strategies and resources to meet the needs of their communities and patients. Didactic presentations remain available through the Mountain Plains ATTC website.

Implementation Strategies for the Project ECHO Model: The Project ECHO model, developed by the University of New Mexico, has effectively dispersed health care knowledge and services to underserved communities using a remote tele-mentoring model across the health care specialties. Implementation of the Project ECHO model in this setting revealed challenges in recruiting and supporting individual practitioners in the case presentation component. Time constraints on the part of practitioners and expert advice from our hub team caused the ATTCs to significantly streamline and modify the case presentation form and questions, focusing on patient strengths and immediate needs. Case presentations in front of hub team experts and a wide multi-regional audience could be somewhat intimidating, and mentoring from the ATTC staff members and local colleagues provided critical support to practitioners who volunteered to participate. Presentations by teams of service providers who were working together to meet the needs of the individual, rather than an individual presentation, also encouraged participation and lowered the barriers for practitioners.

Effective Collaboration between Technology Transfer Centers: The three regional ATTCs discovered effective strategies for collaboration between the regional teams that proved particularly meaningful in the subsequent transition online delivery of training and technical assistance as a result of the COVD-19 pandemic. The Mountain Plains MHTTC summarized these lessons learned in the publication 30 Steps for Cross-TTC Collaborations. Highlights include commitments on sharing expertise, evidence-based practice, agreement on evaluation/engagement on knowledge about outcomes, and practical considerations such as format and method of delivery, external communication and shared staff responsibilities.

Radical Healing: A Viable Response to Racial and Ethnic Inequities in Behavioral Health

Maxine Henry, MSW, MBA

National Hispanic and Latino ATTC

Ethnic and racial inequality has been present in our landscape for generations, yet the COVID 19 pandemic seems to have put a spotlight on the disparities felt by people of color and other minority groups. In a time where the entire world is experiencing overwhelming stress brought on by a virus that has changed our everyday lives, the National Hispanic and Latino ATTC decided to bring together powerful voices to spark conversation and activate positive change in our communities across the nation.

September is a busy month for many in the behavioral health field, as we celebrate National Recovery and Suicide Prevention Month our calendars and social media fill up with important events and inspiring messages of hope, healing and transformation. In many ways it has been a bright spot in the pandemic.

For Latinx community members September also kicks off Hispanic Heritage Month (September 15-October 15), providing us with additional opportunities to commemorate and celebrate our diverse communities. The 2020 theme for Hispanic Heritage Month is “Hispanics: Be Proud of Your Past and Embrace the Future”. In honor of this year’s theme our team decided to host a 4-part Virtual Learning Series titled “The Intersection of Acculturation, Assimilation, and Substance Use Disorder in Latinx Communities: Risk and Resiliency Factors”.

Different from a webinar format, this virtual learning community consists of a returning panel of four subject matter experts who are well respected in the areas of focus: Hector Adames, Psy.D.; Lorraine Moya Salas, PhD; Anna Nelson, LCSW; and Mr. Javier Alegre. The experts spend a short time providing an insight into the research and theories covered in our sub-topics and then have open dialogue with the same small audience of professionals, paraprofessionals, peers, students and leaders from across the U.S. This event is focused on providing a safe space for key stakeholders to gather to discuss the topics of race, disparities and strengths in the Latinx communities they come from and/or serve in the behavioral health space. The goal was to secure engagement in order for the participants to return to their communities and begin to manifest positive change.

Throughout all of our four sub-topics one theme that is consistent is radical healing as a key component to not only coping with racial and ethnic inequities and long-standing collective trauma that is the exacerbated by the pandemic, but to thrive despite the disparities that our communities have felt and, in some instances, contributed to. On its surface radical healing might sound far-fetched or hard to obtain, but once you take a closer look it is a natural strength of many communities. It is based in fundamental tenants often found in the deeply rooted Latinx culture. “Advancing beyond individual-level approaches to coping with racial trauma, we call for a new multisystemic psychological framework of radical healing for People of Color and Indigenous individuals. Radical healing involves critical consciousness, radical hope, strength and resistance, cultural authenticity, self-knowledge and collectivism. (French, Lewis, Mosley, Adames, Chavez-Dueñas, Chen, & Neville, 2019).”

Under this premise we can look back on what our ancestors have taught us, that in times of need we employ familismo, our larger family unit consisting of relatives, friends and community. To heal, recover and thrive from trauma and/or substance use disorders we look to traditional healing, connection and collectivism to take care of ourselves and others. When we face inequities, we rely on our resilience taught to us by our ancestors and family, stand in resistance to racism, and work together to push our families into the future.

Our goal with this event is not only to unpack issues of historical trauma, racism and intersectionality but also to highlight the strength, resiliency and power of our diverse communities. Furthermore, we aspire to use this dialogue as the catalyst for community and systemic change to heal and push forward into a brighter, healthier, more equitable landscape.


French, B. H., Lewis, J. A., Mosley, D. V., Adames, H. Y., Chavez-Dueñas, N. Y., Chen, G. A.,

& Neville, H. A. (2020). Toward a Psychological Framework of Radical Healing in Communities of Color. The Counseling Psychologist, 48(1), 14-46.

Connecting Community and Faith in a Troubled World: The Southeast ATTC’s Faith Leadership Academy

By Pamela Woll, MA, CPS 
and Dawn Tyus, LPC, MAC, NCC
Southeast ATTC

Six months ago, when the world started grinding to a halt, it looked like travel and gathering restrictions might get in the way of the Southeast Addiction Technology Transfer Center’s highly interactive “Let’s Have the Conversation” Faith Leadership Academy, due to start its Immersion Training on April 27. Far to the contrary, the Academy has adapted well to Zoom, and the effects of COVID-19 have many times underscored the urgent need for and importance of the Academy, its lessons, and the leaders it inspires.

If we had any doubts about the complexity of the global pandemic of substance use disorders (SUD), the global pandemic of COVID-19 has wiped out those doubts. The social isolation and unemployment that coronavirus prevention measures created have proved powerful complicating factors for SUD.
  • Substance use has escalated, often to “self-medicate” loneliness, stress, and distress.
  • Access to treatment and recovery support has been reduced, or at best complicated.
  • Overdoses have skyrocketed, due to increases in use and decreases in the human contact that sometimes leads to life-saving measures.

Faith Leaders

The under-resourced SUD field has begun to recognize that engaged, knowledgeable faith leaders and faith communities can be excellent collaborators, “force multipliers,” and bridges between recovery and community life. For many individuals and families, welcome and support from faith leaders, congregations, and faith-based programs can be a catalyst for recovery, a source of referral/resources, and—for some—a primary source of ongoing recovery support.

But even before COVID-19, it wasn’t as simple as opening the doors and carrying a message of faith, hope, and redemption. The stigma, misconceptions, judgmentalism, and shame attached to SUDs:
  • keep many individuals and families away from faith communities,
  • prompt many people to hide or deny their afflictions long after they’ve joined faith communities, and
  • sometimes provoke subtle and not-so-subtle expressions of disapproval that can drive people away from faith communities—sometimes away from faith itself.
Well-prepared faith leaders can seed recovery-friendly cultures within their organizations/congregations, but that’s not simple either. Religious education offers little information or training about SUD, stigma, intervention, referral, or recovery support. Beyond that, it seldom prepares leaders to develop the larger vision, mission, and calling that would help them reach out to surrounding communities and collaborate in transformative efforts to find and help the many individuals and families in desperate need.

The Faith Leadership Academy
Southeast ATTC Director Dawn Tyus and Developer/Facilitator Le’Angela Ingram, MS built the Academy to address just these challenges. Components include:
  • “360 Assessments” synthesizing feedback from superiors, peers, staff, and congregants;
  • one-to-one coaching with the facilitator;
  • a collaborative immersion training for this cohort of 10 faith leaders;
  • webinars with field leaders presenting best practices and emerging trends, followed by discussion sessions within the cohort;
  • extensive reading (e.g., Robert Greenleaf’s Servant Leadership, James Collins’s and Jerry Porrass’s “Building Your Company’s Vision,” Peter Senge’s The Fifth Discipline, John Kotter’s “Leading Change,” and Derron Payne’s The Art of the Pivot);
  • collaborative results-based projects;
  • a booster session; and
  • graduation.
With the inspiration of their individual and collective values, visions, and missions—and the energy and synergy of their collaboration—participants are finishing their projects, including:
  • a regional gathering of faith leaders, a committee to discuss options for linkage to treatment/recovery support, and a multidisciplinary forum on the SUD needs of men in the criminal justice system;
  • training programs (e.g., understanding/identification of SUD, stigma reduction, trauma-informed services, faith leader peer support, forging connections with community resources, starting an SUD ministry, Mental Health First Aid, Wellness Recovery Action Planning, and Resilient Congregations Framework for Ministry) for other faith leaders;
  • a project to establish wraparound services in an impoverished community, a mentoring/support relationship with an under-resourced congregation to establish a Celebrate Recovery program, and a movement to prevent arrests and recidivism; and
  • two video projects, one using personal recovery and faith community experience to educate faith leaders/communities on becoming more welcoming and connecting; and one on empathy, with an accompanying journal/discussion guide for faith communities.

Facilitator Ingram has fond memories of many moments from the Academy, but her favorites are the moments when participants came to her saying things like, “Le’Angela, this is deep!” “This is not lightweight stuff!” and “I have to take more time to be reflective!”

NIATx Principle # 4: Getting Ideas from Outside the Field …Or From Inside Track and Field

By Mat Roosa, LCSW-R
NIATx Coach

The United States has consistently produced some of the best track and field sprinters for decades and decades.

And the United States 4x100 relay teams have been disqualified from a painfully large number of World Championship and Olympic races as a result of dropped batons or botched handoffs.

Why have these best-in-the world sprinters failed so often?

Because relay success requires both speed and the effective management of a multi-step process. In sprint relays, it's all about the handoffs.

Passing the baton around the track is an excellent representation of many handoffs that we see in health care and other industries. Whether we’re talking about products on an assembly line, information, or patients receiving care, the handoff can make or break the product's quality and the customer experience.

The secret of winning sprint teams

Sprint relay teams who have succeeded in winning championships—despite having slower runners than the other teams—have excelled because they have mastered the baton handoff. Contrast this with the American teams, who have been criticized for too much focus on team members' raw speed and inadequate focus on the baton handoff process.

By dissecting a complex process into its component parts and making focused adjustments to enhance efficiencies, you can achieve some amazing results.

Perhaps the less-than-speedy teams have used tools similar to the NIATx method to understand and improve their relay effectiveness:
  • Conducting a Walk-Through (or…a Run-Through) to identify the elements of concern
  • Flowcharting to understand the strengths and weakness of the process, and to identify potential ways to fix those weaknesses
  • Nominal Group Technique brainstorming to identify specific changes to prioritize for action
  • And using Rapid-Cycle PDSA changes to test specific adjustments to the race process

The NIATx model has worked for many organizations in diverse fields making a wide range of improvements.

Not that we are suggesting a NIATx coach for the American sprint relay teams, but maybe ….

About our Guest Blogger

Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in quality improvement, organizational development and planning, and implementing evidence-based practices. Mat also serves as a local government planner in behavioral health in New York State. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat at

Responding to Needs: Collaborations for Broad Impact

By Thomasine Heitkamp, LCSW
PI and Co-Director of the Mountain Plains ATTC and MHTTC

The Mountain Plains ATTC collaborated with the Mountain Plains MHTTC to create a shared product entitled Depression, Alcohol and Farm Stress: Addressing Co-Occurring Disorders in Rural America, [Co-occurring Disorders] April 2020 (M. Shogren, R. Landwehr, D. Terry, A. Moore and A. McLean). This blog discusses the rationale for product development, a brief description of the product, end-user comments, and collaborations with organizations, localities, and states. The topic of co-occurring disorders (substance use and mental health concerns) was identified as a significant training and technical assistance (TA) need in recent formal assessments conducted by the Region 8 ATTC and MHTTC shown below.

In response to this identified need, Region 8 offered training/TA activities and developed products related to treating co-occurring disorders. Given the rural and frontier nature of Region 8, the issue of treating co-occurring disorders requires an examination of this topic in the context of farming families and their communities. 

The Co-occurring Disorders product was produced to assist Region 8 behavioral health providers to improve and enhance their skills in treating co-occurring disorders. Users of this product are provided a fictitious case scenario that walks them through applications regarding use of screening tools (AUDIT-C, PHQ-2, PHQ-9, Health Leads, SIREN) to determine the needs of a farmer who is ultimately diagnosed with an alcohol use disorder and depression. The Co-occurring Disorders product also underscores the importance of family supports, referral to treatment, provider flexibility, and addressing compassion fatigue. The 66-page product includes evidence-based resources (81 references and 26 resources) and colorful photos to provide a narrative regarding screening and intervention related to co-occurring disorders.

“It was easy to understand, and one of the parts that I really liked was that we followed John through the entire process, from the initial start to the emergency room. I liked that because it was easy to see how it would work into a practice; the storyline and how it is incorporated into patient care and practice.”

“It reminds me that as a primary care provider, you might get a little numb to all the barriers that people are facing.”

Following publication and dissemination of the Co-occurring Disorders product, the Mountain Plains ATTC assessed end-user perceptions, including feedback by advanced practice nurses and APRN students who suggested incorporating this document into health career curricula, especially to prepare primary care providers. All feedback was positive, with a note regarding the informative nature of the product and the practical approach to assisting providers in expanding their capacity to address co-occurring disorders among farmers and rural residents. In less than three months, this product has served as the backdrop for additional training/TA activities provided by both the Region 8 ATTC and MHTTC. This includes:

  • Collaboration with Great Lakes MHTTC and the American Psychological Association to offer two trainings - (1) Approaching and Treating Co-Occurring Mental and Substance Use Disorders in Farming and Rural Communities and (2) Co-Occurring Mental and Substance Use Disorders in Farming and Rural Communities: Assessment, Ethics, and Preventing Compassion Fatigue;
  • Co-authoring a companion piece in June 2020 with Mountain Plains MHTTC and Mid-America ATTC and MHTTC, entitled Farm Stress Facts, Impact of Covid-19, Resources, and Training Needs of Mental Health Care Providers (S. Schroeder, T. Heitkamp, B. Clark, E. Holiday, A. Breigenzer, & S. Johnson);
  • A Mountain Plains ATTC Enhanced Professional Learning series that establishes a learning community to expand treatment capacities on co-occurring disorders.
The Co-occurring Disorders product has been accessed and marketed by multiple organizations, including the RHI hub, the National Rural Health Association, and the National Organization for State Offices of Rural Health, which provided a review in their monthly newsletters. Representatives of the United States Department of Agriculture (USDA) lead offices in the Region 8 states (CO, MT, ND, SD, UT, WY) have received the product and are critical collaborators in working on the topic of addressing farm stress through their numerous office locations. USDA has participated in past trainings and is more readily accessing TTC resources, given this collaboration. This effort reflected meaningful and ongoing collaborations among the TTCs and other behavioral health partners to increase awareness and enhance expertise on how co-occurring disorders are addressed in rural areas.

Thomasine Heitkamp, LCSW, is the PI and Co-Director of the Mountain Plains ATTC and MHTTC. She is a Chester Fritz Distinguished Professor at the University of North Dakota with more than 30 years of experience in behavioral health workforce development.

Technology Transfer and Organizational Resilience in the age of COVID-19

Michael S. Shafer, Ph.D.
Pacific Southwest Addiction Technology Transfer Center
Arizona State University

February 4-6, 2020, 39 behavioral health professionals representing 13 agencies throughout HHS Region 9 gathered in Oakland, California for three days to participate in the PSATTC’s Organizational Process Improvement Initiative (OPII) Change Facilitator Academy, launching a 10-month, long-term intensive technical assistance program. Each agency’s group of newly trained facilitators returned home with a plan to brief their Executive Sponsor (who had previously provided a letter of commitment for staff to attend) and hold an organizational change team kick off meeting within 30-45 days. Schedules were coordinated to ensure that I could travel to and attend each of these meetings; no small feat considering sites were located in two states (CA & AZ) and two Pacific Jurisdictions (RMI & CNMI) half a world away. This wordle, captured at the conclusion of the 3-day Academy, denotes the spirit and emotion of the participants.

These are agencies that were ready for change and innovation; they had applied to the PSATTC OPII program to enhance their ability to do so. Selected agencies were required to survey their staff using the TCU Organizational Readiness to Change Assessment. Academy participants had to view three hours of asynchronous video modules before arriving in Oakland. CEOs had to provide a letter of commitment with specific deliverables and action items associated with the OPII model.

And then COVID-19 happened. Site visits were cancelled, kick off meetings were put on hold and change teams suspended, as agencies responded with immediate crisis management actions to protect staff and patients and begin to reimagine service engagement with clients in a physically-distant manner. One agency executive director approved $80,000 in expenditures related to ramping her agency’s telehealth capacity in the two weeks following implementation of her state’s stay at home order. In late March and early April, however, the most important thing these agencies had to focus on changing and innovating was protecting their staff and patient’s safety.

In the four months since the onset of the COVID-19 pandemic, six of the 13 teams have resumed meeting regularly, virtually, and advancing in the 4-phased OPII model. Two of the agencies withdrew their participation, while one agency postponed their change team launch until July. Our ATTC team pivoted our TA procedures. We launched a series of group and individual agency email and zoom meeting communications encouraging agencies to consider altering their improvement change goal to address agency-pressing COVID related issues (such as telehealth adoption). In lieu planned site visits, I began holding Zoom check-ins with each agency every 4-6 weeks. Using Zoom’s recording and transcription capacities has proven a great innovation for documentation and evaluation purposes! We launched a monthly 1-hour Community of Practice (CoP) Zoom session to introduce virtual facilitation tools and skills (such as Zoom and Mural; this portion of the CoP is called the “spark session”) to support facilitators’ virtual team facilitation skill development. These virtual CoP sessions also afford an opportunity for agencies to check-in on their team progress in the OPII change model, while sharing facilitation successes and struggles. These communications are providing insights into the organizational resilience of these agencies in the face of massive short- and yet-to-be-defined long-term changes, and the impact of an ATTC-mediated technical assistance model on strengthening their capacity for technology transfer and innovation.

ATTC Region 2: Preparing and Managing Natural Disasters

Robert Peralta De Jesus, MA, MHS
Northeast & Caribbean ATTC

The Institute of Research, Education and Services in Addiction at the Universidad Central del Caribe, School of Medicine has provided various trainings for first responders, community leaders and healthcare providers. In early January of this year, with the atmospheric events that occurred in Puerto Rico, being impacted by earthquakes, we developed a series of trainings in order to train first responders, community leaders, and healthcare providers to be able to cover the needs of citizens who were directly and indirectly affected. The first training was Psychological First Aid, based on scientific evidence to help children, adolescents, adults and families to face the immediate consequences of disasters or acts of terrorism. It was designed to reduce the initial distress produced by traumatic events, promote adaptive functioning and coping skills. We then provided a training in Psychological Strategies for disaster recovery so that the trainees could acquire skills in managing distress and coping with the stress caused by the events that occurred. Given the situation that the first responders and healthcare providers were going through, we decided to provide them with the tools and training they would need to avoid Compassion Fatigue. This series of trainings were offered in both languages ​​(English and Spanish) for both Puerto Rico and the USVI, and they were also modified to the COVID-19 pandemic.

As part of our commitment to educate and train during the pandemic, we offered a training titled; Skills for managing the isolation period among people recovering from substance use disorders. This was aimed for first responders, to offer tools to people who are in the recovery process with a substance use disorder, in the face of stressors that can cause social isolation due to the pandemic. Understanding the impact that this can have on the family, we also offered a training titled; How to prepare the family to offer support to a family member who is recovering during isolation.
This training was aimed at mental health workers to provide tools for the families of those still in treatment for substance use disorder during COVID-19, in which everyone must remain at home.

Given the uncertainty of what might happen in the future, we set out to offer training based on TAP 34; Emergency Response Planning: Behavioral Health Services for People Using Psychoactive Substances. Emergency response planning is an institutional standard, as it enables the continuity of essential services for communities in critical circumstances. The effectiveness of a plan depends on its consistency with the needs of the population it serves. This webinar is intended to integrate behavioral health services for people who use psychoactive substances as an essential part of a comprehensive emergency response plan.

It is our expectation to continue to provide trainings to all first responders, community leaders and healthcare professionals so they can provide quality service to all that are in need of there assistance.

Northwest ATTC: Tech Transfer in Action Blog Series

David Jefferson, MSW
Director of Training and Technical Assistance
Northwest ATTC

Over the past three years, in collaboration with the Northwest ATTC, I have led a large technical assistance project to support implementation of Motivational Interviewing (MI) for 200+ members of the behavioral health workforce employed at social service agencies in Whatcom County, Washington. During the course of this targeted technical assistance project, workforce members participated in basic and intermediate MI training workshops and received individualized, skills-focused coaching. In March 2020, when I became the Director of Training and Technical Assistance at the Northwest ATTC and we found ourselves in the midst of the pandemic, with providers being asked to quickly pivot to telehealth, it seemed like the perfect opportunity to build on their MI skills.

In mid-March, local programs discontinued face-to-face sessions and their workforce started providing all services virtually (i.e. phone, video-conferencing). Knowing we had a robust number of MI-trained workforce members, we thought this would be an opportune time to offer them individualized coaching in applying MI in their telehealth services. We speculated workforce members needed to increase their confidence in providing care, needed skills in this new medium, and could use guidance on how to be more effective with MI. We also knew many programs would be overwhelmed with administrative and programs complications related to Covid-19.

In response to this need, the Northwest ATTC developed a MI telehealth coaching protocol and by early April started delivering individualized coaching sessions to 41 workforce members. The coaching sessions were 30 minutes in length and delivered via Zoom. Prior to each coaching session, workforce members filled out a skill development form, which included identifying skills they were interested in developing, and writing out a case scenario. During the sessions, the coach role-played the client and the workforce member practiced his or her skills. The sessions ended with a debrief about what worked well, what were the challenges, and what skills to improve. Workforce members were offered up to four individual coaching sessions, and most completed at least three. In all, we completed 99 coaching sessions through the end of May.

The coaching revealed a depth of dedication and commitment by workforce members, who signed up to advance their skills during a time when their stress was peaking, workloads were more complicated and certainty in their day-to-day lives, hard to find. Workforce isolation prompted us to invite all participants to a one-hour Zoom session with the goal of sharing lessons learned and strengthening community. We asked the 25 attendees to answer three questions in small groups and report their top impressions. Here are the questions and responses.

What have you learned to improve your Telehealth services?
  • Workforce members benefit from setting up a workspace, being prepared to provide guidance and structure for the call and taking responsibility for setting the tone.
  • It is important to start calls by checking in about the basics. Asking the client initial questions like: “is this still a good time?”, “are you in an appropriate location?”, and “do you have privacy?” was critical, prior to exploring their comfort and skill level around using the phone and/or computer for services.
  • Acknowledge the common awkwardness, empathize with your shared dilemma of this new medium, and use humor to defuse the situation.
  • Adjust to shifting goals and respect the silence, not all clients like to talk on the phone.

What MI skills have been most useful?
  • The Four Processes of MI; Engagement, Focusing, Eliciting and Planning are helpful for structuring the call and guiding the conversation.
  • Slowing down helps clients make faster connections
  • Moving away from my “to-do list” and developing an agenda with the client.
  • Open-ended questions and reflection keep the conversation going but the reflections need to be deeper and lean toward what is possible, what is helpful, and what is hopeful.
  • Meaningful and well-crafted affirmations shine a light on clients’ skills and abilities especially during these times when they feel desperate and stagnant. Affirming that they have the resources to go forward helps them identify their self-efficacy.
  • Summaries help start and end the conversations and add structure. They create a story or narrative about the client’s life that is difficult to capture in these two-dimensional settings.
  • Explore the discord, as it helps increase engagement.

What are your pending challenges to strengthen services?
  • Building rapport and making genuine connections over the phone is the hardest part. Not all clients are comfortable with using phones for counseling sessions and do not see the value.
  • Maintaining connections via virtual sessions is hard and must be attended to each time.
  • Ambivalence is on the increase. Everything seems to be put on hold. Encouraging change talk is a bit harder as clients are hesitant to move on, due to fear, etc. (e.g., some have chronic diseases are afraid to go to healthcare providers).
  • They want Covid-19 information, which is limited, so it triggers the desire to fix clients and leaves workforce members feeling like they did not help.
  • Hard to move people to the eliciting phase. Need to make use of looking forward strategies to build hope and rekindle dreams.

Offering this cohort an opportunity to practice their MI skills with mock client role-plays, seemed well timed, and many expressed their appreciation and gratitude. The success of the project led the Northwest ATTC to offer the same opportunity starting in late May to the Idaho behavioral health workforce and we are exploring the possibility of expanding in other areas in region Ten.

Addressing the Syndemic of Addiction, COVID-19, and Structural Racism by Strengthening the Workforce

By Sara Becker 
New England ATTC

According to the latest data from the Centers for Disease Control and Prevention, over 105,000 Americans have died and at least 1.7 million Americans have been infected with the novel coronavirus disease (COVID-19). Social distancing measures put in place to contain the spread have decimated entire sectors of the United States economy, with the stock market dropping so precipitously that it erased three years of gains. Unemployment rates are also at historically high levels with the national rate rapidly approaching 15%. In a few short months, COVID-19 has upended our country and harmed millions of Americans.

Data on the toll of COVID-19 are troubling in aggregate, but even more concerning when we consider those Americans hit the hardest. Recent commentary by NIDA director Nora Volkow (2020) underscored how individuals who use opioids are at increased risk for the most adverse consequences of COVID-19 due to both direct (e.g., slowed breathing due to opioid use) and indirect (e.g., housing instability, incarceration) pathways. In addition, Black Americans and Hispanics have been disproportionately affected by COVID-19: emerging regional data suggests that the COVID-19 death rate for Black and Hispanic Americans is about 2.5 times higher than for whites. The disproportionate toll of disease reflects the effects of structural racism, which manifests in increased risk of underlying health conditions (e.g., chronic respiratory disease); decreased access to testing and care; and decreased ability to socially isolate due to factors such as crowded living conditions and employment in sectors deemed essential. Taken together, these data indicate that the United States is in the midst of a syndemic - defined as the interaction of a set of linked health problems involving two or more conditions, interacting synergistically and contributing to excess burden of disease. Addressing the syndemic of addiction, COVID-19, and structural racism requires responses on multiple levels and across multiple fronts. One of those fronts is ensuring that the addiction treatment workforce is equipped with the tools needed to help patients facing these interacting epidemics.

The Addiction Technology Transfer Center (ATTC) Network has been working to meet this challenge by developing new products and resources focused on these intertwined public health issues. The National Coordinating Office hosted a Listening Session and a 5-part Strategic Discussion Series focused on emerging issues around COVID-19 and social determinants of health. The Listening Session solicited feedback on ways COVID-19 has highlighted racial and ethnic disparities, and each Strategic Discussion focused on concrete actions that could be taken to support specific communities of color.

Regional ATTCs have also risen to the challenge to create new tools for the addiction workforce during these unprecedented times. The New England ATTC has developed multiple products including a 2-part webinar series (in partnership with the New England Mental Health Technology Transfer Center) focused on the intersection of addiction, mental health, and COVID-19; a training focused on Trauma-Informed Approaches to Substance Use Assessment and Intervention (which includes new content on how to sensitively assess and address the trauma of racism and the traumas inflicted by COVID-19); and a workshop on Cultural Intelligence and Cultural Humility (which has been adapted to address the disparities and racism highlighted by COVID-19). The New England ATTC has also partnered with the South Africa HIV ATTC to develop a series of products focused on provider self-care in recognition of the toll that caretaking places on front-line health professionals. Finally, in October 2020 the New England ATTC will proudly host this year’s national Addiction Health Services Research Conference (delivered fully virtually)! One of the plenary talks by Dr. Ayana Jordan will specifically address the intersection of structural racism and addiction, and spotlight awards will be given to addiction researchers from underrepresented minority groups.

The New England ATTC is proud to join other Regional ATTCs in not only building the skills of the SUD workforce but also providing supportive strategies for sustaining hope and encouraging self-compassion during this trying times. Please visit the New England ATTC’s COVID-19 resource page to see the latest products and training events devoted to addressing this syndemic.

How to Reduce No-shows to Virtual Appointments

Todd Molfenter, Ph.D.
Director, Great Lakes ATTC, MHTTC, and PTTC

Is this a familiar scenario for your organization?

Day 1: Stay-at-home order: Your agency enacts social distancing guidelines.

Day 3: Your agency has switched in-person counseling to telephonic or video-based counseling.

Day 12: Virtual services, particularly telephone, have increased engagement rates!

Day 30: The honeymoon is over: show rates to virtual appointments are decreasing, especially among new consumers.

In the COVID-19 era, an old nemesis has returned: appointment no-shows. While telehealth has removed some barriers to behavioral health services, other engagement challenges are emerging. Agencies can take the “how exactly are we going to do this?” approach that COVID-19 has thrust us into since the beginning.

Another way is to turn to existing tools and proven practices to address the new no-show dilemma.

Three Tips to Reducing No-Shows During COVID-19 and Beyond
Apply these three tips, in this order, and watch your no-show rates decrease and show-rates increase.

1. Track No-Show Performance 

You can’t improve what you do not measure. No-shows should be measured. Measure no-shows to virtual appointments the same way you measured no-shows to in-person appointments before COVID-19. Compare no-show rates pre- and post- COVID. Segment the data as needed: new vs. existing client; by client age; by appointment type, etc. This measurement creates a foundation for improvement.

2. Use PDSA Cycles!

The Plan-Do-Study-Act (PDSA) method creates a simple process to test new approaches and observe their impact on no-shows. (See related post from NIATx coach Mat Roosa: Learning from Crisis: PDSA in Times of Challenge.) Plan a change; Do a change; Study the impact of the no-shows; then, Act on the change. (Adopt, adapt, or abandon.) You can conduct PDSA Cycles as part of an organized agency-based improvement initiative. Or, individual clinicians can perform PDSA cycles to improve their show rates.

What are good practices for addressing no-shows in a PDSA cycle? See Tip 3:

3. Use Proven Practices to Reduce No-shows
While COVID-19 provides us with some very new situations, we can learn a lot from what’s worked in the past to reduce no-shows.

Open scheduling: Book appointments to accommodate consumers’ schedules. Evening hours? Weekend hours? Ask the consumer, “When would you like us to talk next?”

Reminder calls, e-mails, and text messaging work for virtual appointments as well as they do for in-person appointments. Note the scheduling of the reminder message or text: Two days prior seems to work best for in-person appointments; one day before or on the day of for virtual appointments.

Evidence-Based Practices to Reduce No-Shows

Use Motivational Interviewing (MI) to reduce no-shows by increasing the consumer’s interest in coming back. The growing evidence base for MI shows its effectiveness in a variety of settings.

Use incentives or Contingency Management. Contingency Management is proving to be an effective EBP to enhance retention, particularly for stimulant use disorders. Offer consumers an incentive to reward attendance: a recognition certificate, gift card, or other small prizes.

Learn more about Motivational Interviewing and Contingency Management through the free online courses available through HealtheKnowledge, the ATTC Network’s online learning portal.

Patient no-show trend analysis can identify high-risk no-show patient categories (new vs. existing patients, payer source, patient age) as well as situations (day of the week, time of day, location). Develop patient scheduling practices to increase show rates from identified areas. This practice is particularly relevant as we need to understand better when, where, and how virtual appointments have greater participation.

Interested in learning more about how you can use these tips to reduce no-shows in your organization? Watch for information on the new Virtual NIATx Change Leader Academy—details available soon on the Great Lakes ATTC, MHTTC, and PTTC websites.

What have you found most useful in increasing participation in virtual care? What conditions and practices hurt appointment attendance? What have helped? Let us know in the comment section below.

Dr. Todd Molfenter is the deputy director of the Center for Health Enhancement Systems Studies at the UW-Madison. He is also the director of three SAMHSA-funded Technology Transfer Centers: the Great Lakes Addiction Technology Transfer Center, Mental Health Technology Transfer Center, and Prevention Technology Transfer Center. Todd specializes in implementation science, with a particular focus on technology and evidence-based practices in behavioral health.