BCI Reaches Reluctant Clients by Creating "Windows of Trust"

BCI’s Safety Net Services is featured in this month’s CSAT Grantee Spotlight. We’re pleased to reprint it for you here. Pictured from left: Case Manager Sharon Brown, Nurse Joyce Bunkley, Nurse Practioner Chris Zebley, and NSAFE Manager Rhonda Swanson.

Basha Silverman is the Director of HIV Prevention Services at Brandywine Counseling in Wilmington, Delaware, and is the Project Coordinator of its Safety Net Services project. Sharon Brown is the Case Manager for the Safety Net Services project. We spoke with Basha and Sharon about this TCE/HIV grant and discussed their challenges, solutions, and lessons learned.

Grantee Profile
Brandywine Counseling provides behavioral health services to individuals with substance abuse problems and their families. It is Delaware’s largest provider of outpatient addiction treatment services.

Brandywine provides opioid treatment, drug-free treatment, mental health treatment, and case management. It includes pregnant and parenting women’s services, a drug court program, an infectious diseases clinic, and an HIV prevention unit.

Safety Net Services is a multicomponent project offering integrated addiction pretreatment, treatment, and HIV/AIDS services. It incorporates outreach, HIV education and testing, medication management, and co-occurring disorders treatment. This grant targets women and ex-offenders and creates a safety net for at-risk and HIV-positive substance abusers at various stages of readiness to enter addiction treatment.

What are your unique challenges?
Clients have unique patterns of willingness, readiness, and commitment to treatment. They become interested, engaged, and disinterested, and leave, return, and cycle back and forth.

When engaged, clients visit us often, bring their babies, visit our clothes closet, and use our dropin services. We view these as special windows of opportunity to make use of clients’ motivation to change. But these windows can close quickly, challenging our ability to remain engaged.

Co-occurring mental health issues are notable challenges. When clients don’t have rapid access to mental health medications or professionals, their windows of opportunity can rapidly close and their treatment needs may be left unmet.

How do you address these challenges?
Since client willingness and readiness are dynamic processes, we make engagement methods flexible and dynamic. We meet clients where they are, not where we want them to be.

When clients stop coming to us, we reach out to them. But they shy away if outreach is coercive or pushy. Thus, we use gentle motivational interviewing techniques during outreach. We meet clients at times convenient to them. They are often on the street in the early mornings.

Our Case Manager will conduct outreach between 4:00 a.m. and 7:00 a.m. At such times, clients are often tired and willing to talk and join the Case Manager for coffee and donuts and discuss treatment. Many clients are willing to enter treatment on the spot. Since our program accepts intakes at 5:30 a.m., the Case Manager can take advantage of windows of opportunity and help admit clients immediately.

To enhance outreach effectiveness, our Case Manager has multiple roles. All of our clients are assigned a counselor and a Case Manager. Our Case Manager is an active part of the counseling team and conducts follow-up locating and outreach. Thus, clients already have a relationship with her. She is a friendly face.

We promote treatment-on-demand to address mental health challenges. CSAT funding helped us expand the roles and hours for our nurse and nurse practitioners. They previously worked only with HIV clients but now work with HIV clients and those with co-occurring disorders. We were also able to increase physician and psychiatrist time. These changes increased access to psychiatric evaluations and medication management. Having our Case Manager coordinate appointments further increased access and reduced waiting lists.

What lessons would you like to share?
Program and client goals can be at odds. A program may seek to achieve 80 percent abstinence, which is commendable. But clients may have such goals as getting a home or a job, leaving an abusing spouse, or reuniting with their children. They may want to be better spouses or parents.

We can improve the lives of our clients best if we use goals and milestones that are client-centered, realistic to each client, and take into consideration the resources in the community and clients’ lives.

We implemented several process improvements that resulted in reduced waiting time and increased admissions. To do so, we had someone anonymously walk through the admission process and experience it from a client’s perspective. This revealed delays to make appointments, complete the intake and assessment paperwork, enter treatment, and receive lab tests.

We convened a committee to analyze the processes. We took steps to reduce appointment times, shortened the admission process by eliminating duplicate admission and assessment paperwork, and reduced lab delays from weeks to hours by using same-day lab tests.

How has GPRA data collection helped you?
Asking the GPRA tool questions fosters thoughtful and probing discussions with clients. It helps to create relationships with clients and opens up windows of trust and intimacy. Asking the GPRA questions helps us to better understand clients’ lives, experiences, treatment needs, and resources.

This article is reprinted with permission from CSAT Discretionary Grantee News, July 2009.