NIATx: The Intersection of Behavioral Health and Systems Engineering — A Conversation with David H. Gustafson

By David H. Gustafson, PhD, Director, Center for Health Enhancement Systems Studies, and Maureen Fitzgerald, Communications Manager, Great Lakes ATTC, MHTTC, and PTTC

Update: In Memoriam

It is with deep sadness that we acknowledge the passing of Don Holloway, who made significant contributions to the NIATx model. 

Learn more about Don’s legacy.

Dave Gustafson

Dave Gustafson directs the University of Wisconsin−Madison’s Center for Health Enhancement Systems Studies, which includes the Great Lakes ATTC, MHTTC, PTTC, NIATx, and several research projects that focus on using systems engineering tools to support sustainable individual and organizational improvement. His individual and systems change research develops and tests technology to help people deal with issues affecting quality of life, including addiction, cancer, and aging.

In this post, Dave reflects on the enduring impact of the NIATx model.

When NIATx launched in 2003, did you envision it expanding and continuing to grow 20 years later?

"No, it was not a long-term view at all. The Robert Wood Johnson Foundation (RWJF) was interested in whether systems engineering could help in the addiction space. Victor Capoccia, a project officer with RWJF, contacted me and asked if I wanted to run a national program focused on improving addiction treatment. I knew nothing about addiction treatment, so I played the role of someone with an SUD and tried to get myself admitted for treatment in a couple of places. I wanted to make sure that the program we set up with RWJF would make a difference. Our vision was very short-term — what we could do in the 3 or 4 years of the funding period. We did not expect the project to have an extended life beyond the initial funding in 2003.”

What was something that surprised you in the NIATx evolution?

“The biggest surprise was recognizing how little I knew about what it takes for your work to have a broad impact. Victor Capoccia was always thinking about NIATx at a much broader level and set the direction for us. He'd call me and say, "OK, I've set up a meeting with Congress so we can talk about this," or, "I think we can hold a national conference."

Other things came up, but I wouldn’t refer to them as surprises—more like accidental discoveries. Some of the changes we made came about just from conversations. One that stands out is a conversation I had with Dean Lea, one of our NIATx coaches for the first project. Dean and I were driving back from a visit to a treatment center in Maine that Lynn Madden (a current NIATx coach) was directing. We’d been looking at appointment books from a lot of agencies and could see from the packed schedules that there was no room for new patients. But we could also see how many appointments were canceled or no-shows. While the field as a whole was saying they could not meet demand, agencies often had 35% unused space. Dean said, "I don't know why people even bother to schedule appointments because nobody shows up.”

So, we went back to Lynn and talked about not scheduling appointments. This turned into trying out the idea of (what Lynn called) on-demand appointments. That solution just took off. So that's one solution we came up with by accident, not planning. 51% of innovations come up by accident, not by planning. It was an Aha! moment that made a tremendous difference in treatment access. As Einstein said, "If we knew what we were doing, it wouldn't be research." It’s the stumbling along that brings about great ideas.”

What do you think has contributed to NIATx expansion?

“Many things contributed to NIATx expansion. A top factor was staying focused on our original four aims: reducing waiting time, reducing no-shows, increasing admissions, and increasing continuation. Don Holloway, who was part of the team that launched NIATx, told me to really drive that message whenever I got in front of a group to talk about what NIATx was and was not. Staying focused on just those four aims  (and nothing else) at a time made the change projects manageable for our providers versus feeling overwhelmed by the idea of having to overhaul their systems completely. Maintaining that single focus was important.

I also think that the simplicity of the NIATx change model is what makes it so powerful. We told providers that they only had to follow five principles—not 10 or 15—and that they only had to try a change for a very short time. If it worked, great. But if didn’t, then stop and try something else. The idea was to keep NIATx simple and fast-moving enough so people could easily adopt it.

Another factor in our success was the doors that Victor Capoccia and Fran Cotter from SAMHSA opened and their commitment to the project. SAMHSA-funded projects led from a focus on individual treatment agencies to the role of state agencies and the tremendous impact they can have on treatment delivery.

I would add research as another factor contributing to the NIATx trajectory, with work by Todd Molfenter, Jay Ford, and others helping drive widespread implementation and testing in new spaces. Plus, the NIATx Change Leader Academy (CLA) that we launched in 2006 has played a huge role in dissemination efforts and has trained hundreds nationwide.  Mat Roosa and Scott Gatzke continue to refine the CLA to respond to the field’s evolving needs, including work with Alfredo Cerrato on applying NIATx tools to foster cultural responsiveness. That’s really exciting. 

And then, the stories. How many times have I told the story of creating a persona of someone with a heroin addiction and then trying to get my persona admitted for treatment? How I was told to call back for seven weeks in a row to find out if a bed was available when my persona was ready for (and needed) treatment that day! While the science is there, it’s anemic compared to a great story. And, of course, the ATTC/NIATx Service Improvement Blog has been a great way for sharing these stories over the past decade.”

Are you using NIATx tools in your current research?

“The NIATx approach is embedded in the way I think about things and continue to integrate into everything I do. One project that’s been a great interest of mine for some time is the idea of automating addiction treatment, or in other words, finding ways to explore how technology, and that includes AI, can play a role in prevention, treatment, and recovery. The NIATx model of rapid cycle improvement is playing a fundamental role in that effort right now.”

What aspects of your current research are you most excited about?

“One of our current initiatives involves weekly Zoom meetups with around 60 older adults. We kick things off by having participants break into small groups to share something positive or challenging that’s happened in the previous week. We spend the initial 10 minutes in open conversation, then shift gears—assigning someone to lead a discussion on a weekly theme. It could be something as straightforward as dietary choices for older adults, a shared concern for everyone. Then, a member of our research team will give a brief but informative lecture on the topic, followed by a wrap-up 30-minute discussion where everyone pitches in with their thoughts. Towards the end, we summarize the key takeaways and wrap up with a movement exercise.

The impact has been astounding. I initially thought the idea of bringing people together on Zoom was good, but it turns out it's a great idea! I've never experienced such a profound response before. People are emotionally moved, and some have even teared up when they learn that the intervention is coming to an end. That leads us to ask what the next step is. What's the message here, and where is this taking us? It's been a powerful journey, and the participants' emotional response speaks volumes about this project's impact.”

Guest Post — Still Reaching: The Syndemics that Complicate and Characterize How Drugs and HIV Intersect in People’s Lives

 (Editor's note: This post originally appeared on the National Institute on Drug Abuse blog. It is reprinted here with permission from NIDA.)

By Dr. Nora Volkow

Imag

Nearly 42 years ago, the Centers for Disease Control and Prevention (CDC) reported a rare pneumonia in five gay men, marking the recognized start of the HIV/AIDS epidemic. While we often hear about those men’s sexuality, we hear less often about their substance use. As the 1981 report notes, one of those five men injected drugs, and all five used drugs.

The history of HIV has long been entwined with substance use. In the United States today, more than 30,000 people acquire HIV every year while the drug overdose crisis cost the lives of nearly 107,000 people in 2021. Research shows people with HIV are more vulnerable to drug overdose than are those without HIV.

Because substance use plays such a significant role in HIV transmission and in health outcomes for people living with HIV, the National Institute on Drug Abuse (NIDA) is one of the largest funders of HIV research at the National Institutes of Health (NIH). We highlight the stories behind this essential research in the video series, “At the Intersection: Stories of Research, Compassion, and HIV Services for People Who Use Drugs.”

What is a syndemic?

Syndemics happen when two or more diseases interact to amplify each other—leading to an excess burden of disease and perpetuating health disparities. In a syndemic, environmental and social factors, like lack of quality healthcare, can make people more likely to be exposed to and experience worse outcomes from diseases. Having one health condition can also make people biologically or behaviorally more likely to acquire another illness.  However, science shows that when we address syndemic diseases together, outcomes for both can improve—especially when we integrate a variety of medical and social services with community support programs.

Approaching HIV, substance use, and other health issues through this lens can identify new opportunities to intervene that are invisible when we look at each issue alone.

Methamphetamine use, HIV, and mental health issues

A 2020 NIDA-supported study showed that as many as one in three new HIV transmissions among sexual and gender minorities who have sex with men were in people who regularly use methamphetamine. Many participants reported using methamphetamine to enhance sexual experiences, sometimes called “partying and playing.” Other NIDA-funded research shows that individuals who use methamphetamine are more likely to have sex without HIV prevention; to have mental health issues like depression, anxiety, or bipolar disorder; and are more likely to have detectable HIV viral loads and less likely to take HIV treatment and prevention medication. Fortunately, approaches that emphasize compassion and flexibility over judgement show promise in helping people who use meth achieve their health goals, take medication, and reduce their drug use or stay safer when they are using.

Substance use, HIV, and syringe sharing

Since 2014, there have been at least nine HIV outbreaks associated with the sharing and reusing of syringes in communities of people who inject drugs. CDC- and NIDA-funded researchers have identified factors associated with such outbreaks, including higher rates of hepatitis C and drug overdose, poverty, and lower levels of education. Fortunately, decades of research show that syringe services programs are safe, effective ways to reduce syringe sharing—and with it, the risk of acquiring HIV. Today, many syringe services programs also offer the overdose antidote naloxone and medications for opioid use disorder (MOUD), as well as HIV testing, prevention tools and treatment.

Substance use, HIV, and stigma, criminalization, and violence

People with HIV and substance use disorder (SUD) struggle to access quality, evidence-based healthcare. Racism, homophobia, transphobia, and HIV- and SUD-related stigma in healthcare are serious problems. Policies that punish drug use and criminalize HIV status can lead to time in jails and prisons, where access to HIV and SUD services may be limited. Immediately after incarceration, people are at greater risk of overdose and of leaving HIV care.

These factors—plus high rates of intimate-partner violence (especially among transgender and cisgender women living with HIV), childhood abuse, and other trauma—mean many people face intersectional factors leading to poor HIV and substance use outcomes. But NIDA-funded research shows promising ways forward, including integrated care that addresses the totality of people’s lives. For example, “one-stop” clinics—like the mobile health units in the NIDA-supported INTEGRA trial—test the impact of offering comprehensive services delivered by trained peer navigators who can connect with participants’ diverse experiences.

Bottom Line

Meeting people where they are to provide harm reduction and healthcare without stigma and treating the totality of people’s lives offers hope. And that hope is essential to ending the HIV epidemic.

NIATx in New Places: RHRP

By: Mat Roosa, LCSW-R

“How can we improve our workforce?”

In a human service environment filled with open positions, understaffed programs a low rates of worker retention this seems like a perfectly reasonable question. 

As NIATx has continued to explore new places, we have turned our attention to trying to support the workforce challenges of health and human service organizations. The critical need for this support emerged from the experience of attempting to support programs in implementing NIATx based change projects, but finding that the change leader supervisors were struggling to keep enough staff to operate the program, and had little energy for improvement. Some consultants and providers of technical assistance have been struck by the level of stress related to workforce concerns that supervisors are experiencing. Too many supervisors express a high level of stress and moral injury, as they find themselves unable to pursue the mission that they care deeply about, because they do not have the staff to do it. 

So, we decided to use our improvement model to help organizations to answer that question: “How can we improve our workforce?”  And upon further inspection we found that this might not be the right question to ask.

One of our NIATx principles is to get ideas from other industries, and so we found ourselves thinking about how a similar question might play out in another environment. What if a customer went into a grocery store and asked the front-end manager, “Where can I find the dinner food?” We all know why this would not be an appropriate question. It is just too generic to be meaningful. The response would likely be some version of “It depends on what you want to eat.”  

The work of Deming teaches us that everything we do can be defined as a process. And workforce issues are no exception. It became clear that any effort to support workforce improvements needed to use our NIATx tools to break down the issue into the specific processes. These included recruitment, hiring, retention, and promotion (RHRP). The NIATx tools of the walk through and flow charting could then be used to understand the potential applicant or interviewee’s experience associated with that specific process. Nominal group technique brainstorming could then help to define specific strategies for recruitment, or hiring that could be tested using the PDSA (plan, do, study, act) change model. 

We have begun to use this approach to train supervisors and managers to make specific changes and to measure the results to see if they can recruit more diverse candidates, get more people to apply for positions, enhance the interview experience, etc. In addition to the NIATx model, we have also included other key factors, including cultural responsiveness, wellness, and coaching/ mentoring to provide additional support to the workforce improvement effort.

There is certainly no single fix to the complex economic drivers of workforce challenges. But the use of focused data driven change projects can help an organization or a broader system, to find strategies that can make a difference. Harnessing the wisdom of a change team to find new paths forward is a key part of NIATx. Using PDSA change cycles is helping leaders to impact these workforce challenges in simple and powerful ways. 

Mat Roosa, LCSW-R

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 process improvement, evidence-based practices implementation, and organizational development and planning. 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.

Addiction Technology Transfer Center (ATTC) Network: Celebrating 30 Years of Empowering Professionals

By Greg Grisolano, for the ATTC Network

Technology transfer is in our name, but do you really know what it is?

 

Even though the Addiction Technology Transfer Center (ATTC) Network has been a leading expert in the field of substance use disorders since 1993, we realize there are still some folks who don’t know who we are and what we do.

 

We provide professionals with free training, tools, and support to help those in recovery and facing substance use disorders. The ATTC Network offers evidence-informed education, technical assistance, and custom resources aimed at strengthening the skills of practitioners. By listening to the needs of local, regional, and national partners, the ATTC ensures it stays relevant and effective, working to empower professionals and foster a thriving, recovery-oriented system of care.

Recently, we launched a new series of explainer videos that provide an overview of the organization’s mission and services. The videos are available in both English and Spanish and are designed to be accessible to a wide range of audiences.

What is the Addiction Technology Transfer Center (ATTC) Network? - Full Length from ATTC Network on Vimeo.

In addition to these explainer videos, the ATTC Network recently celebrated its 30th anniversary. As part of this celebration, we released a timeline highlighting significant accomplishments over the past 30 years. The timeline includes information about how the organization has grown over time and how it has adapted to meet changing needs in the field of substance use disorders.

Our 30th anniversary celebration also included a virtual event that featured remarks from SAMHSA Assistant Secretary Dr. Miriam Delphin-Rittmon and Dr. Yngvild Olsen, director for the Center for Substance Abuse Treatment (CSAT). During this event, attendees had the opportunity to learn more about the organization’s history and its plans for the future.

Watch the ATTC Network’s 30^th Anniversary Celebration

 

The ATTC Network is helping to empower practitioners and foster a thriving, recovery-oriented system of care. 

NIATx in New Places: Insights on Using NIATx in Prevention

By Erin Ficker, Prevention Manager, Great Lakes PTTC, and Maureen Fitzgerald, Communications Manager Great Lakes ATTC, MHTTC, PTTC

Erin Ficker, CPRS, MPAff, has over 18 years of experience in substance use prevention, helping communities adopt evidence-based strategies and data-driven processes for prevention planning and execution. Since 2019, Erin has teamed up with NIATx coach Scott Gatzke to conduct NIATx Change Leader Academies for prevention professionals. An August 2023 CLA for prevention included four 90-minute weekly virtual sessions over four weeks.

According to Erin, prevention has always involved elements of process improvement. “During the implementation phase of prevention programs, it’s very common to review data and make  mid-course corrections," says Erin. “But a structured approach to this process has been the missing piece. NIATx provides a great framework for addressing this gap."

In the August prevention CLA, Erin and Scott revamped the language and presentation to resonate with the prevention audience. For example, NIATx Principle #1: “Understand and involve the customer,” was fine-tuned to “Understand and involve the participant,” with prevention participants identified in multiple settings: community, schools, government, and families.

Erin and Scott also work to reframe the concept of  “process” within the context of prevention work. "Prevention professionals don’t typically view their work as process-driven. We used the flowcharting tool to help participants identify their prevention work as processes, while integrating quality improvement concepts."

She continues, "Processes in prevention are less obvious than, say, the daily routines in hospitals dealing with new mothers and babies, which are straightforward to define. In areas such as recruiting coalitions and implementing policy, it may not always be apparent that there are well-defined processes at play.”

NIATx Tools

Erin cites the Plan-Do-Study-Act (PDSA) cycle as one of her favorite tools for streamlining the change process. She explains, "Prevention efforts often require ongoing adjustments and enhancements. The PDSA cycle enables a coalition to make gradual, incremental changes to their strategies and interventions and then assess the impact of those changes.” 

The training offered sample prevention-focused aim statements to guide a prevention-focused PDSA Cycle:

• Increase number of schools using Project Towards No Drug Abuse program from 7 to 11 by April 
• Increase number of parents completing 80% or more of Strengthening Families sessions from 20 to 50% by May
• Increase coalition meeting attendance from 50 to 85% by March

Another favorite NIATx tool for Erin is the Nominal Group Technique (NGT). "The NGT has been a game-changer for engaging participants in structured idea generation,” she says.

“Aha!” Moments

“Participants saw the potential for these tools to enhance their work, even though they had not yet identified a specific change project,” says Erin.

“For the next iteration of the prevention CLA, we’re planning to embed activities in the sessions that will give attendees the skills to apply what they’ve learned immediately.”

The Great Lakes PTTC will offer a NIATx Change Leader Academy for Prevention Professionals again in 2024.

Erin Ficker, CPRS, MPAff, serves as a prevention manager for the Great Lakes PTTC. She has worked in substance use prevention for more than 18 years, supporting communities to use evidence-based strategies and data-driven processes in substance abuse prevention planning and implementation. Erin works with community-level prevention practitioners and schools to develop, implement, evaluate, and sustain prevention interventions.