Decreasing Elopements in LBWs Dual-Diagnosis Residential Treatment Centers

Executive Summary
At LBW, Level II Residential Treatment was developed to be a 24-hour 4-6 month treatment program for individuals
with serious mental illness and substance abuse diagnoses. To ensure positive clinical outcomes, the expectation is that
clients complete treatment; however, many clients elope (leave) before program completion.
Residential managers had identified a trend in clients leaving treatment shortly after intake. This project was further
identified by the Notice of Action & Incident Report Committee (NOA/IR Committee). One of the committees goals is to
decrease Incident Reports. LBWs Quality Improvement data showed that the highest quantity of incident reports within the
organization is from client elopements in Residential Treatment Centers; therefore, it was identified that a project to decrease
elopements would benefit the organization due to the effects on key business issues:

Financial Impacts
Customer Satisfaction
Clinical Outcomes
Perceived Quality of LBW Services
Organizational Growth & Innovation

The scope of this project is limited to client elopements. The data does not include clients that were asked to leave before
program completion or clients that had other forms of planned discharges. The data does, however, include client elopements
that did not result in Incident Reports, to allow for a greater range of data analysis. Although it has been identified that there
are several critical to quality factors that affect a clients decision to remain in program (motivation, support, appropriate
referral for level of care, etc), this project is limited to the objectives of increasing awareness of the program description and
ensuring agreeableness before entering treatment.
An affinity diagram was developed through an NOA/IR Committee brainstorming activity to explore potential
causes of clients leaving program before completion. A SIPOC diagram and process flow chart were then developed to
visualize the current processes and key input and output variables. By creating a p-chart in Minitab, additional data was then
analyzed regarding the proportion of defects.
On August 15, 2014, there was a change in the referral and intake process. Because it was identified that clients may
not be agreeable or aware of the program description and expectations, the LBW Residential Program Information Sheet was
developed and implemented. This occurred along with a process change in the supplier of the information. The Residential
Program Information Sheet is included with every referral that is sent from the RBHA to the case management team. Before
a client comes into program, it is expected that the case manager is reviewing the sheet with their client to ensure
agreeableness to treatment.
Using Six Sigma strategy, data analysis indicated that the average number of days increased from 17.85 days to
27.82 days in program (a 56% increase), which indicates a successful process change. In the first 30 days of treatment,
percentages of client elopements dropped 86% to 79%. By decreasing the percentages of elopement and decreasing
variability, there is a successful impact on profitability and clinical outcomes.
Changing the supplier of program information appears to have improved the referral and intake process. It is
recommended that the NOA/IR committee continue collecting and analyzing data to ensure performance is maintained. As
the data is analyzed, special causes should be determined. By decreasing the defects and variation in the process, there is
greater predictability, less wasted resources and rework, and better clinical outcomes.

The Improvement Opportunity: The Define Phase

At LBW, Level II Residential Treatment was developed to be a 24 hour 4-6 month treatment program for
individuals with serious mental illness and substance abuse diagnoses. The goal is for all clients that enter treatment to
successfully complete treatment. The issue is that many clients elope (leave) before program completion.
Residential leadership had identified a trend in clients leaving treatment shortly after intake due to disagreement
with program description. This project was further identified by the Notice of Action & Incident Report Committee. One of
the committees goals is to decrease Incident Reports. Quality Improvement data showed that the highest quantity of incident
reports within the organization is from client elopements in Residential Treatment Centers; therefore, it was identified that a
project to decrease elopements would benefit the organization due to the effects on key business issues.
Financially, open beds affect the profitability of the organization. There are a large amount of resources invested in
post-elopement processes and intake processes. Because we bill per diem, if a client does not stay the first night in their bed,
there is a loss in resources invested in the intake. Approximately 9% of intakes leave without staying the night in their beds;
therefore, we currently account for a loss of approximately 9% of the intakes that we complete. In addition to this, we are not
able to bill for the time that the bed is open leading up to the next intake, which is typically 7 to 10 days in length.
Success rates could potentially impact the satisfaction of the Regional Behavioral Health Authority (RBHA), which
contracts between providers and the state. There is an opportunity to close the gap between the RBHA expectations and our
performance by decreasing the number of elopements. Increased elopements also cause increased resources needed by RBHA
case managers, which decreases Provider Network Organization (PNO) satisfaction with our services.
When staff resources are utilized on intake and discharge processes, there is an impact on the resources available for
client care, innovation, and service improvement. Perceived success rates are lower when clients leave before treatment
completion, which has an impact on employee morale and quality performance data.
Because elopements have such a large impact on key business issues, the overall goal for this project is to analyze
data to determine whether a change in the referral and intake process positively impacts clinical outcomes and profitability.
The objective is to increase the average length of stay before elopement, particularly increasing length of stay beyond the
critical time periods that have been identified. The reason this goal has been identified is because of the trends of elopement
in the first week of treatment. These elopements have the largest impact on business issues because of the lead times between
referral and intakes and the resources involved in intake and discharge processes. Overall success will be evaluated by an
increase in average number of days before elopement and decrease in percentage of elopements in the critical time periods.
Improving performance will help improve profitability and clinical outcomes.
Performance: The Measure Phase
Post April 1, 2014, all referral data was entered onto a referral tracking spreadsheet. The data was then simplified to
allow for baseline analysis. Data was deleted for any client that completed program, clients that received notice of actions
(involuntary treatment discontinuation), and for referrals that did not present for an intake. Data was collected from referral
information on admit dates, elopement dates, and sites where intakes occurred. Additional data was then collected through
the electronic health record. This data primarily focused on client demographics (age, gender, diagnoses). The data was then
organized in charts to allow for brainstorming and hypothesizing.
Current Performance Level: To identify current performance level, we looked at data to identify when elopements
are occurring. Currently, we can see a trend in intakes that elope during critical time periods. Figure 1 illustrates that 9% of
total elopements occur at 0 bed days, or before billing begins; 22% of elopements leave within 1 bed day; and 41% of
elopements leave within 3 bed days. By Day 8, 62% of elopements occur. After Day 8, the data tends to remain relatively
constant, with the exception of a spike around Day 14, and Day 27. Currently, 86% of elopements occurred within the first 30
days of treatment. The average length of stay before elopement is 17.85 days.

Target Performance Level: We wish to increase the average number of days before elopement by 10%; therefore,
our target performance level is an average of 19.64 days before elopement. We would also like to see a 5% decrease in
elopements during the 30 day critical time periods.

Cri9cal Time Periods

Count of Client Elopements

April 1, 2014 - August 15, 2014

10
8
6

36%
22%
9%

41%

0
SIPOC Analysis:
0 1

44%
2

49%
53%

62%

Total

56%
7

9 10 11 12 14 18 22 24 26 27

Number of Bed Days in Program

Figure 1: Critical Time Periods of Client Elopements

Note: This chart only includes data from elopements; It excludes data from clients that may have completed program, clients whom received NOAs, or
clients whom are currently in program.

Analysis and Interpretation: The Analyze Phase
In an NOA/IR committee meeting, it was discussed that there is a trend of elopements soon after intake. The
NOA/IR committee members then organized and summarized natural groupings to understand the essence of the problem.
An affinity diagram was developed through a brainstorming activity to explore potential causes. The brainstorming activity
led to the following potential problem statement: Clients are not aware of the program description and expectations before
presenting to an intake. This problem statement was also in line with leaderships hypothesis that clients are not well
informed about the treatment program where they were referred.
A SIPOC diagram and process flow chart (Figure 2) were then developed to visualize the current processes and key
input and output variables. In the process shown in Figure 2, clients do not receive information about the program until they
arrive at intake. During the intake, the client learns about the program for which they received a referral, and may decide that
the program will likely not meet their needs. Often, the clients case manager encourages the client to try it for a few days
since the client is already at the facility and has partially completed the intake. At this point in the process, the client has
already prepared for move-in to the facility and has ended other services or living arrangements so they are more likely to
follow the aforementioned advice of their case managers.
When the program information is relayed to the client at such a late stage in the process, it has an effect on the
chances of the client staying in program and completing treatment. If the program does not meet their expectations, the client
will not complete treatment, which has an impact on clinical outcomes, organizational revenue, and client satisfaction.

Suppliers

Inputs

RBHA

Referral

PNO CM

Transports client
to intake

Process

Client
Completes
Program

Program
Information
relayed to client
LBW Staff

Outputs

Clinical
Outcomes

Customers

Behavioral
Health
Recipient

Program
Information
relayed to PNO
Case Managers
Intake Paperwork

Figure 2: SIPOC Diagram & Referral/Intake Process Flow Chart

By creating a P chart in Minitab 16 (Figure 3), additional data was then analyzed regarding the proportion of defects.
A defect is defined as a client that stays in program for less than 3 bed days, which equaled approximately 41% of clients. To
measure how much variation is in the process, process sigma was calculated. With a sample of 58 (N), there was 1
opportunity for each defect (O), and 24 total defects (D), there were 41.4% Defects per Opportunity.

Figure 3: Minitab P-Chart

Recommendation: The Improve Phase

Alternative Solutions Considered by NOA/IR Committee:
Additional Screening- LBW staff could meet with clients prior to intake to ensure each client is an appropriate
referral whom is agreeable to the program description and expectations. Additional screening would also help staff
identify client motivations for treatment, which would help predict length of stay. Additional screening may be an
effective solution, although it would be somewhat costly due to the amount of resources involved in screening
clients. This would also increase the lag time before intake, which would also be costly. Overall, it would likely be
more profitable than non-screening; however, there may be less costly solutions.
Additional staff supports at intake- Additional staff could improve customer service at intake. An intake specialist
position would support staff in completing the intake process, which would also improve staff satisfaction,
ultimately improving the clients intake experience.
Welcoming Programs- Developing a welcoming program at each site could help new clients adjust to the program.
Welcoming programs may also help clients feel like a part of their new community and may decrease elopements.
There would be little cost involved in this program development and implementation, although it may not be as
effective as alternative solutions.
Recommended Solution: To decrease client elopements in the first 3 days of treatment, we need to ensure the client is
fully aware of what to expect from LBW Residential Treatment Centers. To increase this awareness prior to intake, we need
to supply the program information before the client presents to an intake. Because LBW staff members often do not have
contact with the client until the intake/move in, the supplier (refer to Figure 2) could be changed to the PNO Case Manager
so that the input (program information) can occur earlier in the process to decrease elopements in the first few days. This
solution does not require additional resources from LBW and could potentially have a positive impact on revenue.
On August 15, 2014, a Residential Program Information Sheet was developed and implemented. This sheet provides
information about the program to increase client awareness and understanding of the program description and expectations.
The Residential Program Information Sheet is included with every referral that is sent from the RBHA to the case
management team. Before a client comes into program, it is expected that the case manager is reviewing the sheet with their
client to ensure agreeableness to treatment. With this process change, we expect that more clients may decline referrals;
however, we expect that this change in process will cause an overall decrease in client elopements shortly after entering
treatment, and therefore have a positive impact on organizational revenue.
From August 15, 2014 - January 21, 2015, referral data continued to be collected for analysis of the effectiveness of the
Residential Program Information Sheet. A Minitab control chart (Figure 4) demonstrates that after the implementation of the
Residential Program Information Sheet, there was a decrease in the number of defects per unit. Additionally, as seen in
Figure 4, there was a sharp decline shortly after the Residential Program Information Sheet was implemented, which likely
indicates the effectiveness of this change in process. In the following months, the proportion of defects increased, however
remained below the average.

Pre - Residential Program Info Sheet

Post - Residential Program Info Sheet

Figure 4: P Chart April 2014 - January 2015

Percentage of Elopements

Additionally, the average number of days increased from 17.85 days to 27.82 days in program (a 56% increase),
which indicates overall success. In reviewing the percentage of elopements during critical time periods, there was a reduction
in the overall trend line (Figure 5). We noticed no significant changes in the first day in treatment, although the overall
percentages of elopements in all other critical time periods were decreased. In the first 3 days of treatment, percentages
dropped from 42% to 39%. In the first 8 days of treatment, percentages dropped from 62% to 48%. And in the first 30 days
of treatment, percentages dropped 86% to 79%. By decreasing the percentages of elopement and decreasing variability, there
is a successful impact on profitability and clinical outcomes.

100%

Resi Program Info Sheet impact on Elopement Percentages

With Forecast of Elopement Trendline

80%
60%
40%
20%
0%
0

14

30

Number of Bed Days

Sum of Post-Info Sheet

Sum of Pre-Info Sheet

Linear (Sum of Post-Info Sheet)

Linear (Sum of Pre-Info Sheet)

Figure 5: Percentages of Elopements during Critical Time Periods Pre- and Post- Residential Program Information Sheet.

The Control Phase

In January 2015, the proportion of defects increased, which could indicate that the process is no longer being
followed as originally planned. On January 21, 2015, the Residential Program Information Sheet was updated to include a
case manager signature, verifying review of the information with the client. The goal is that this will increase likeliness of
thorough review of the form with their client. With this form update, there was also a change in process. Intakes will not be
scheduled until the Residential Program Information Sheet is signed and returned to LBW staff. Program Coordinators were
made aware of the new intake scheduling protocol to ensure the process is followed. The NOA/IR committee plans to
continue monitoring data to ensure performance improvement. If the data does not improve with this change in process, there
may be other special causes that are attributing to the increase in defects in January 2015.

Conclusion
When Residential leadership and the NOA/IR committee both identified concerns with the number of elopements in
LBW Residential Treatment Centers, we began brainstorming solutions for improvement. Using Six Sigma strategy, there
was a 56% increase in the average number of days before elopement. The proportion of defects in the first 3 days of
treatment was decreased. Additionally, there was a 7% decrease in the percentage of clients that eloped in the first 30 days of
treatment.
It is recommended that we continue collecting and analyzing data to ensure performance is maintained. As the data
is analyzed, special causes should be determined. By decreasing the defects and variation in the process, there is greater
predictability, less wasted resources and rework, and better clinical outcomes.