Reducing Paperwork

Reducing the amount of time patients spend in the administrative process of intake and assessment is a key issue identified by NIATx. The main goals of reducing waiting and no shows and increasing admissions and continuation are all better served by a rapid intake process. The amount and type of paperwork that clinic staff and patients have to complete or process is an area that facilities will likely need to address when considering any process improvement. And although this sounds like a common sense approach to fixing one area of the clerical process that could slow down or complicate matters, there has been no empirical evidence found that directly relates a change or reduction in paperwork with increased admissions and continuation or a reduced wait time.

The literature does discuss changes made to certain procedures to streamline systems. Often, part of this process improvement involves changes to the type and amount of paperwork used. Dennis et al (1994) document changes to the admission process that helped a methadone maintenance clinic reduce wait time from intake to treatment from over 14 days to less than 2 days. Part of that change was how they handled acquiring certain administrative information. Clerical staff were trained to conduct preadmission intake interviews over the phone, setting up the appointment and conducting a liability assessment. Although not discussed, when patients came in for their intake appointment, staff would be able to focus more attention on assessing the clients’ needs instead of making sure they had the appropriate documentation. The process improvement this clinic implemented led to a reduction in wait times as well as increased admissions.

As part of CSAT’s Target Cities initiative, communities implementing Central Intake Unit’s to increase and streamline admissions to treatment were also required to create a Management Information System (MIS) that allowed tracking of clients through the treatment system. Several articles discuss the components that make up the MIS but none provide any empirical evidence that this increased access to treatment or helped insure patients moved smoothly through different levels of care. Shwartz et al (1999) described the MIS used with the Boston Target Cities program. The main components of the Massachusetts Substance Abuse Management Information System (SAMIS) was the Bureau of Substance Abuse (BSAS) admission form which standardized collection of socio-demographic information as well as a discharge form which recorded information on discharge status. Additionally, the Addiction Severity Index (ASI), the Primary Care Assessment (PCA), case management logs and a referral system used to track clients as they moved from central intake into treatment were also part of the SAMIS. Use of the SAMIS did standardize many forms and documents used by the central intake units in tracking patients.

Soldz et al (2002) devised a test to determine the reliability of the SAMIS. SAMIS consists of admissions, discharge and billing databases and while it is used for many management, evaluation and research purposes, users consistently express concerns regarding the quality of the data. The results found that all variables show some amount of reliability. Also, the authors feel the variables most relevant for treatment planning have moderate to high reliability.

Becnel et al (1999) discuss the changes implemented in getting the New Orleans Target Cities initiative up and running. As part of that initiative, acquiring an MIS to support central intake procedures was essential. The original MIS was only used at one central intake unit and included a CSAT short intake screener instrument. The use of this standardized intake tool along with increases in intake personnel, reduced the average wait time for intake from 14 days to less then 48 hours. With the final phase of the MIS now implemented, the New Orleans Patient Tracking System allows the various central intake units to share information over a system wide network.

The use of standardized assessment and placement tools like the Addiction Severity Index (ASI) and the American Society of Addiction Medicine Patient Placement Criteria (ASAM PPC) have been recognized as effective tools in meeting the goals identified by NIATx. By using technology, the way these tools are administered can lead to a reduction in paperwork and streamlining of the admission process. Brodey et al (2004) showed the validity of a web based and interactive voice response (IVR) telephone version of the ASI. These automated systems have the potential to reduce labor costs while increasing access to treatment as patients are able to complete these forms from home. The potential benefits of these system changes are an area that requires further study.

As does the entire topic of Paperwork reduction. The available literature on this subject is extremely limited. Studies need to be performed which specifically address process improvements which limited the amount of paperwork used or duplicated and the impact these changes had on treatment engagement. The Target Cities initiative did show that a centralized, accessible database used to track patients could be implemented and Soldz was able to show that its data was reliable.